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DEBATE Open Access

Appraisal of the Karnofsky Performance Status

and proposal of a simple algorithmic system for
its evaluation
Dominik Pus1*, Nicolas Newcomb2 and Silvia Hofer3

Abstract
Background: For over 60 years, the Karnofsky Performance Status (KPS) has proven itself a valuable tool with which
to perform measurement of and comparison between the functional statuses of individual patients. In recent
decades conditions for patients have changed, and so too has the KPS undergone several adjustments since its
initial development.
Discussion: The most important works regarding the KPS tend to focus upon a variety of issues, including but not
limited to reliability, validity and health-related quality of life. Also discussed is the question of what quantity the
KPS may in fact be said to measure. The KPS is increasingly used as a prognostic factor in patient assessment. Thus,
questions regarding if and how it affects survival are relevant.
In this paper, we propose an algorithm which uses a minimum of two and a maximum of three questions to
facilitate an adequate and efficient evaluation of the KPS.
Summary: This review honors the original intention of the discoverer and gives an overview of adaptations made
in recent years. The proposed algorithm suggests specific updates with the goal of ensuring continued adequacy
and expediency in the determination of the KPS.
Keywords: Karnofsky performance status, Quality of life, Disability evaluation, Algorithms, Neoplasms, Review

Background symptoms) to 0% (death). The ECOG Performance

The Karnofsky Performance Status (KPS) is a widely
used method to assess the functional status of a patient.
It was introduced by David A. Karnofsky and Joseph H.
Burchenal in 1949 in an article originally published as a
chapter of the book Evaluation of Chemotherapeutic
Agents, edited by Colin M. MacLeod [1]. This book
summarized the results of a symposium in New York in
1948, and it is for this reason that the original article is
not listed in PubMed. Originally entitled Performance
Status, the term Karnofsky Performance Status was
coined at a later date, and renamed after the author of
its creation.
The KPS describes a patients functional status as a
comprehensive 11-point scale correlating to percentage
values ranging from 100% (no evidence of disease, no
* Correspondence: dominik.peus@usz.ch
1
Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
Full list of author information is available at the end of the article
Status (ECOG PS), an alternative status assessment, was
developed by the Eastern Cooperative Oncology Group
and derived from the KPS [2]. For years, the KPS and
ECOG PS have been important tools in clinical practice.
In clinical trials the two assessment methodologies are
used as selection criteria (similar to processes for selec-
tion using age or gender) and for the stratification of
subgroups in test patient cohorts. Along with disease
staging in terms of tumor size, e.g. TNM, the KPS has
established itself as a decision aid with relevance regard-
less of whether a patient is to receive either tumor-specific,
or merely symptomatic treatment.
Furthermore, independent of the role it plays in treat-
ment modality decisions, the KPS has also established
itself as a salient prognostic factor in a variety of tumor
entities.
Despite the prevalent role it holds in general oncology,
the body of literature pertaining to the KPS scale is

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relatively succinct; most significant work regarding it
was developed in the 1980s.
A central theme of this article is definable by the
following question: How is it possible that a subjective
value assigned by clinicians within a matter of seconds,
is given the same or even greater prognostic significance
than many objective values? The objective values
referred to in this case being, for example, prognostic
estimates based on genetic testing, elaborate staging
investigations, etc. The question posed here does not
intend to doubt the importance of various objective
methodologies, nor their continued development, rather
it seeks simply to demonstrate that the financially free
and quickly detectable value, KPS, carries undeniable
weight, and that due to this its critical evaluation
remains a relevant issue.
Discussion
Questioning the adequacy and objectivity of the KPS
Subjectivity versus objectivity of the KPS
When evaluating the KPS questions arise regarding both
its objectivity and validity. Indeed, questions of objectivity
and the influence of chemotherapy on KPS scores were
already engaging David A. Karnofsky in the early days of
cytotoxic drug research in the 1940s. At the time he made
the incisive observation that whenever a chemotherapeu-
tic agent succeeds in relieving symptoms, this results in
the subjective judgment that it is effective by the patient
concerned; the treating clinician, however, must rely on
objective criteria to evaluate a drugs efficacy. In response
to this, David A. Karnofsky developed criteria which even
today remain valid for the assessment of chemotherapy:
Table 1 Karnofsky performance status
Condition
A: Able to carry on normal activity and to work. No special
care is needed.
B: Unable to work. Able to live at home, care for most personal 70
needs. A varying degree of assistance is needed.
60
C: Unable to care for self. Requires equivalent of institutional or 40
hospital care. Disease may be progressing rapidly.
The unbracketed text is the original text of Karnofsky and Burchenal, 1949, while in square brackets [], the newly formulated KPS values 40% - 10% of Abernethy
et al., 2005, may be found.
Page 2 of 7
tumor size, laboratory parameters (e.g. anemia), length of
remission, and overall survival. All of these criteria share
commonalities in that they are discretely measurable and
therefore objectifiable. According to Karnofsky, symptoms
such as general weakness, vomiting, skin rashes and pain
were to be considered subjective variables - subjective,
because they were not precisely quantifiable and could be
erroneously influenced by subjective experience, as well as
personal factors and interests.
Not to be ignored, however, the objective assessment
criteria listed above may not be taken as the only basis
for patient evaluation. They fail to provide any informa-
tion regarding the overall state of a patient or the extent
of his or her independence or need for supportive care.
In this context, Karnofsky introduced the Performance
Status, [] describing the patients ability to carry on
his normal activity and work, or his need for a certain
amount of custodial care, or his dependence on constant
medical care in order to continue alive. These simple
criteria serve a useful purpose, in our experience, in that
they measure the usefulness of the patient or the burden
that he represents to his family or society. [] [1].
The percentages of the KPS describe three states
(conditions): A (10080%), B (7050%) and C (400%).
These states describe different levels of performance.
Functionality and performance comprise the core
concerns of the KPS (Table 1).
Inter-observer reliability
Questions regarding the subjectivity of KPS scoring
include the critical evaluation of inter-observer reliability
for the methods involved in KPS evaluation. The most
Percentage Comments
100 Normal, no complaints, no evidence of disease.
90 Able to carry on normal activity, minor signs or symptoms of disease.
80 Normal activity with effort, some signs or symptoms of disease.
Cares for self, unable to carry on normal activity or to do active work.
Requires occasional assistance, but is able to care for most of his
needs.
50 Requires considerable assistance and frequent medical care.
Disabled, requires special care and assistance. [In bed more than 50%
of the time].
30 Severely disabled, hospitalization is indicated although death not
imminent. [Almost completely bedfast].
20 Hospitalization necessary, very sick, active supportive treatment
necessary. [Totally bedfast and requiring extensive nursing care by
professionals and/or family].
10 Moribund, fatal processes progressing rapidly. [Comatose or barely
arousable].
0 Dead.
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important studies on the KPS are from the early 1980s.
In one study Yates et al. recruited clinical nurses and
social workers to independently measure KPS scores in
52 hospitalized patients (Pearson product moment
correlation = 0.69). The Pearson product moment corre-
lation is a measure of the linear correlation between two
variables. Additionally, an at-home KPS evaluation was
performed by the social workers for the same patients.
This produced a corresponding Pearson product moment
correlation coefficient of 0.66 [3].
In Mor et al. 47 testers were recruited and trained to
accurately assess the KPS. After 4 months, these testers
had to repeatedly generate KPS score evaluations in the
form of written patient descriptions. The Cronbachs
coefficient alpha was used to determine inter-observer
reliability which was greater than 0.97, with a maximum
of 1.00. The validity of the approach was further
assessed by accompanying KPS evaluation with two
additional physical function tests. These were the Katz
ADL index [4], and an overall quality of life assessment
which was conducted at the initial interview and at each
subsequent contact involving an interview assessment
[5]. In this manner, the predictive value of the KPSs
relationship to life expectancy in a population of terminal
cancer patients was effectively demonstrated [6].
In 1984 Schag et al. had 293 cancer patients complete
a questionnaire on physical and psychosocial stress [7].
Two different groups of testers (oncologists and mental
health professionals) then assessed the KPS of these
patients. The reliability of the KPS between different
observers was measured i.a. using the Pearson product
moment correlation, which was 0.89. Interestingly, how-
ever, the doctors generally attributed higher scores than
the mental health professionals. In the same paper, using
multiple regression analyses, seven behavioral issues
were empirically identified which might assist in the
improvement of the evaluation of individual KPS scores.
The seven variables were weight loss or gain; decreased
energy; difficulties with walking, driving or personal
hygiene; and the inability to engage in normal work habits.
The authors suggested that an additional questioning of
the patient regarding these seven variables might facilitate
a more precise determination of the patients KPS [7].
The authors Schag et al. speculated that the lower
reliability observed by Yates et al. might be related to a
greater proportion (63%) of patients with low KPS scores
(KPS 70%) than was present within their own study
(47%) [7]. Newer studies also suggest difficulties in the
accurate determination of KPS scores for patients with
reduced performance statuses [8,9] because KPS values
between 40% and 10% indicate the need for hospitalization
as a criteria (Table 1). Today there are many alternatives
to avoid hospitalization, especially in a palliative setting, a
fact which contrasts with the more limited medical care
Page 3 of 7
possibilities available in the 1940s. The Australia-modified
Karnofsky Performance Status (AKPS) is an example of an
attempt to address the inconsistency presented due to the
original KPSs inadequate reflection of current medical
practice by reformulating the KPS criteria for values
between 40% and 10% [8]: 40%, in bed more than 50% of
the time; 30%, almost completely bedfast; 20%, totally
bedfast and requiring extensive nursing care by profes-
sionals and/or family; 10%, comatose or barely arousable.
Abernethy et al. validated the modified KPS in 2005 as
part of a randomized controlled trial with palliative
patients. The aim of the study was to show that the AKPS
has the same predictive value for overall survival as the
original KPS in a specialized palliative setting. 26 clinical
nurses were trained to determine performance scores. The
KPS and the AKPS were then determined simultaneously
for the 306 participants at 1600 timepoints. Although the
AKPS score results correlated strongly with those derived
using KPS, they proved in fact to be more accurately
predictive regarding the survival of palliative patients
classified under KPS condition C.
Influence of KPS on survival
In the last thirty years various studies have demonstrated
the prognostic value of the KPS, primarily for various
cancers [10-13], but also for other disease entities [14].
The examination of certain of these gives the impression
that the KPS itself affects survival - which of course is
impossible, except for perhaps indirectly. The KPS is an
artificial construct which measures the ability to func-
tion. Important for survival is not the KPS percentage
score, rather it is the disease state and co-morbidities,
and the impact of these two items upon the patients
vitality. A disease may cause, for example, due to its
consumptive nature and disruption of specific organs or
organ systems, specific disorders which limit a patients
independence and self-sufficiency.
The symptoms which are caused by a disease are
assessed and weighted simplistically by the KPS classifi-
cation according to their provocation of functional
impairment. Therefore, the assessment of overall physical
functionality as a predictor of overall survival is quite
understandable pathophysiologically because poorer prog-
noses are generally associated with increasingly severe
symptoms and a greater burden of disease.
The reverse conclusion, that the KPS measures the
vitality of an individual patient is also fallacious. For
example, a single, stable brain metastasis in the motor
cortex is capable of massively limiting patient indepen-
dence, even if the organism on the whole remains largely
unaffected by the tumor, resulting in the protracted
survival of the patient despite a severely reduced KPS. In
contrast, another patient in the course of the same
underlying disease may rapidly perish due to liver
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metastases with subsequent liver failure, despite only
shortly before death having enjoyed a relatively high
degree of autonomy. The relative overall survival of the
second patient was much shorter, irrespective of his KPS
score, due merely to the relative pathophysiological
advantage of the first patient. This example illustrates
that patient vitality depends on many factors other than
merely the KPS, including but not limited to TNM
staging, age, gender, molecular genetic markers, etc.
On the other hand, the two patients described above,
who might as well have been characterized by similar
TNM staging, age, gender and genetic marker profiles,
help to demonstrate that the KPS offers an important
additional evaluatory tool. In the words of David A.
Karnofsky, While it is important to know that subjec-
tive and objective improvement have been produced, the
picture is filled out if we also know whether the patient
remained flat on his back or was able to return to work.
[1]. The advantage the KPS offers is the ability to
reproducibly quantify impairment.
KPS to assess the quality of life?
The importance of the KPS as a tool for assessing quality
of life is a regularly discussed topic in the relevant litera-
ture [15,16]. One important definition of health related
quality of life (HRQoL) is that which has been developed
by the World Health Organization [17]: Quality of life
is defined as an individuals perception of their position
in life in the context of the culture and value systems in
which they live and in relation to their goals, expecta-
tions, standards and concerns. It is a broad ranging con-
cept affected in a complex way by the persons physical
health, psychological state, level of independence, social
relationships, and their relationship to salient features of
their environment. Use of the KPS as a measurement of
quality of life has historically been and correctly
continues to be a controversial topic as it is abundantly
clear it can only capture some limited aspect of the
broader concept. It simply was not designed with the
explicit intent of addressing the inherently expansive set
of questions posed by quality of life considerations. As
Mor et al. recognized, the KPS is, when applicable,
primarily useful in the assessment of the overall physical
quality of life [6]. The false conclusion that the KPS is
an adequate measure of the quality of life is probably
derived from the fact that every loss of function or loss
of independence may legitimately be perceived as carry-
ing far-reaching, individually variable effects at physical,
physiological and psycho-social levels, thereby influen-
cing the processes of sickness. Therefore, cases where a
loss of physical function fails to affect quality of life
would appear to be the exception.
Unfortunately, within this context, it has become
evident that adequate and accurate measurements of
Page 4 of 7
quality of life historically played only a minor role in
controlled studies [16]. Today, quality of life is gene-
rally assessed using comprehensive evaluatory question-
naires [18].
Differences between ECOG PS and KPS
With respect to a patients functional status, the Eastern
Cooperative Oncology Group Performance Status
(ECOG PS) [2], also called the WHO Performance
Status or Scale, is an often used alternative to the KPS.
The ECOG PS scale ranges from 0 (healthy, no pain) to
5 (death) (Table 2). According to the literature, major
advantages of one method over the other do not seem to
exist. The KPS, due to its eleven-stage classification, as
compared to the six-stage ECOG PS classification, is
somewhat more precise. Most notably, ECOG PS usage
in the case of a poor functional status leads to inad-
equate over-simplification [19]. A study has shown, how-
ever, that the ECOG PS does perform somewhat better
than the KPS when estimating lung cancer prognoses
[10]. Other studies have demonstrated minor benefits
regarding reliability in favor of the KPS [20], or, despite
statistically same intra-observer reliability, better inter-
observer reliability favoring the ECOG PS [21]. The
differences in frequencies of use of the two methods
within various oncological sub-specialties may best be
explained historically. The KPS plays, for example, an
important role in neuro-oncology; in contrast the ECOG
PS plays a more important role in many other onco-
logical sub-specialties. On PubMed, over the course of
the last 5 years, the number of annual publications
found using a general search for the term Eastern
Cooperative Oncology Group Performance Status or
ECOG PS has increased from 104 to 238 items; for the
term Karnofsky Performance Status an increase from 208
to 270 items is observable. Thus, although prevalence falls
in favor of the KPS, the annual increase in publications
referring to the ECOG PS is greater.
Table 2 ECOG performance status
Grade ECOG
0 Fully active, able to carry on all pre-disease performance
without restriction
1 Restricted in physically strenuous activity but ambulatory
and able to carry out work of a light or sedentary nature,
e.g., light house work, office work
2 Ambulatory and capable of all selfcare but unable to carry
out any work activities. Up and about more than 50%
of waking hours
3 Capable of only limited selfcare, confined to bed or chair
more than 50% of waking hours
4 Completely disabled. Cannot carry on any selfcare. Totally
confined to bed or chair
5 Dead
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Proposal for a simple, efficient and goal-oriented KPS
evaluation
The absence of a KPS classification scheme has been
criticized by a variety of groups in the past. Keeping the
significant works of Mor et al. and Schag et al. [6,7] as
well as the newly developed Australia-modified Karnofsky
Score [8], in mind, this paper would propose a method to
facilitate the simple, efficient, and goal-oriented evaluation
of the KPS in clinical practice. Three principle ques-
tions orient themselves according to the tripartite,
conditional classification (A, B, and C), proposed in
David A. Karnofskys original article (Table 1).
The first question (1), Is the patient able to carry on
with his/her normal work or activity?, provides stratifi-
cation between state A (able to carry on normal activity
and to work) and the states B and C (unable to work)
(Figure 1). If question (1) is answered in the negative,
question (2), Is the patient bedridden for more than half
a day?, provides further differentiation between the
states B (not able to work) and C (not capable of self-
care). Subsequent to this, in each case, only one further
question is necessary to determine the exact KPS
percentage score. Specifically; in state A, Does the patient
have symptoms?; in state B, Does the patient need assist-
ance?; and in state C, What is the patients degree of
disability in terms of bed confinement?.
The questions focus upon functional capacity. Ques-
tion (2) is based on Abernethys findings and is intended
to avoid the inadequacies of the originally proposed
criteria for KPS values from 40% to 10%. In the majority
of cases the proposed questions are clearly answerable
and result in a consecutive, relatively discrete categoriza-
tion within the 11-point scale. In everyday clinical prac-
tice the proposed algorithm system would likely prove
helpful, especially to those individuals still inexperienced
in performing a KPS evaluation.
Although the algorithm proposed is based on the
conventional classification, the measurements which are
carried out using the algorithm might not necessarily be
completely consistent with previous non-algorithmically
obtained measurements. A prospective study to validate
and assess the algorithm would be desirable. A good
method to achieve this would be through equivalence-
testing between the KPS, the AKPS, and the proposed
algorithm. A study consisting of three groups of exa-
miner participants and a shared patient pool would be

Initial questions Follow-up Symptom characterization KPS Comments

questions %
Is the patient able to No symptoms. 100 Normal, no complaints, no
carry on with his/her evidence of disease.

normal work or activity? Does the patient

have symptoms? Mild symptoms. 90 Able to carry on normal

A (pain, loss or gain of

weight, reduced energy
activity, minor signs or
symptoms of disease.
YES etc.) Moderate symptoms. 80 Normal activity with effort,
some signs or symptoms of
disease.

NO No assistance. 70 Cares for self, unable to

carry on normal activity or
to do active work.
Does the patient
need assistance? Occasional assistance. 60 Requires occasional assis-
B (grooming, food intake,
dressing, other daily
tance, but is able to care for
most of his needs.
activities)
NO Considerable assistance. 50 Requires considerable assis-
tance and frequent medical
care.

Is the patient Bedridden in more than 40 Disabled, requires special

bedridden for more care and assistance.
50% of the time.
than half a day?
Almost completely 30 Severely disabled, hospitali-
bedridden. zation is indicated although
death not imminent.
YES What is the Completely bedridden and 20 Hospitalization necessary,
very sick, active supportive
C patients degree of
disability in terms of
dependent upon extensive
nursing care by professio-
treatment necessary.

bed confinement? nals and/or family.

Completely bedridden 10 Moribund, fatal processes
and comatose or barely progressing rapidly.

arousable.
Dead. 0 Dead.

Figure 1 Proposed algorithm system for the evaluation of the Karnofsky performance status. The initial questions are answered with yes
or no answers to discriminate between three statuses: A, B and C (see Table 1). The following questions further distinguish 11 derivative KPS
values (1000%). The items in round brackets () in the follow-up questions lend further suggestive clarification (Schag et al., 1984). The symptom
characterization is based on the works of Karnofsky and Burchenal, 1949, and Abernethy et al., 2005 (Table 1).
Pus et al. BMC Medical Informatics and Decision Making 2013, 13:72
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a sensible means to this end. The examiners would
have to be instructed regarding the measurement of
conventional KPS, AKPS and KPS as conducted accor-
ding to the proposed algorithm, and the measurements
of the three groups of examiners regarding the shared
patient group would need to be conducted indepen-
dently, but still as temporally consistent as possible, to
avoid erroneous errors due to fluctuations in the condi-
tions of individual patients over time.
Unresolved issues regarding the KPS
What does a KPS score of 100% mean for an oncological
patient? David A. Karnofsky describes a KPS score of
100% as normal, no complaints, no evidence of disease
(Table 1). The first two items are relatively easily
accepted and assessed. But what of the third item, no
evidence of disease? Is the judgment to be made here
meant purely to be based on external, clinical findings,
irrespective of, for example, available imaging or lab
diagnostics? In everyday practice, experience has demon-
strated that many patients are assessed to have a KPS of
100% as long as they are independently functional and
symptom-free; this is done despite their having some
form of cancer and therefore demonstrable evidence of
disease. In the literal sense a KPS of 100% must be
considered a true rarity among oncology patients.
Are unwanted treatment effects (radiation, chemothe-
rapy) reflected by KPS estimates? In everyday clinical
practice, a common occurrence is that a patients KPS
score is evidently reduced due to the initiation of treat-
ment or intervention, at least initially. Does this carry
the consequence that it is only possible to reliably evaluate
KPS scores under the relatively static conditions which
exist before and after treatment?
What KPS score might adequately describe, for
example, a young, hemiplegic, wheelchair-dependent
glioma patient, who otherwise has no symptoms and
works full time? In this case, is a lower KPS score
justifiable?
Who should perform a KPS evaluation? Typically, the
KPS is assessed by the supervising oncologist. Research
results show, however, that this evaluation could be done
by the nursing staff, or even by the patient.
And what of the somewhat vague formulations of KPS
comments such as, 40% or less? Are the revisions pro-
posed by Abernethy et al. a solution to this?
A consensus on these issues, as well as adequate in-
struction regarding the performance of KPS evaluation,
are important factors to maximizing the comparability
of KPS evaluations on separate patients over time, and
to ensure the consistency of KPS measurements between
clinical trials. The proposed algorithm is an attempt to
standardize the process and therefore the results of KPS
evaluation.
Page 6 of 7
Summary
In summary, the KPS is an artificial construct which
measures a patients activity level using an 11-point
scale. One may postulate that the objective assessment
of the functional status of a patient is accessible using
the KPS. Objectivity of this assessment is limited, how-
ever, by the fact that it is individuals with personal values
who perform KPS evaluations, and that many patients
may demonstrate rapid fluctuations regarding their
self-sufficiency.
The algorithm system proposed by this work may be
of use in clinical practice. It allows for the standardized
and efficient assessment of the KPS score through the
posing of a minimum of two, and a maximum of three,
questions. A prospective study with the aim to investi-
gate the proposed algorithms applicability and validity is
necessary.
The KPS allows for the classification and stratification
of patients whose clinical conditions are often highly
complex. Along with the ECOG PS, it is the only
method for stratifying patients in a vast and mixed arena
of heterogeneous diseases and disabilities. That the KPS
is adequately assessable in a variety of individual patients
is the foundation of its applicability. It should not, how-
ever, be misinterpreted as a measure of quality of life.
The significance of the KPS as an important predictive
value of overall survival must not be underestimated.
The assessed factor, functionality, as a determining fac-
tor for overall survival, may depend upon other elements
which are not taken into account by the conventional
KPS evaluation.
All in all, body functions exist in a permanent and com-
plex interdependency with activity, participation, personal
and environmental factors. Clinically, the KPS of a patient
must be evaluated within this framework thereby assessing
some of the aspects of all of these factors.
Abbreviations
KPS: Karnofsky performance status; AKPS: Australia-modified karnofsky
performance status; ECOG PS: Eastern cooperative oncology group
performance status; HRQoL: Health related quality of life; TNM: TNM
classification of malignant tumors.
Competing interests
The authors declare that they have no competing interests.
Authors contributions
DP conception, review the current literature, drafting manuscript. NN
drafting manuscript. SH supervision, drafting manuscript. All authors read
and approved the final manuscript.
Author details
1
Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.
2
Institute of Biomedical Ethics, University of Zurich, Zurich, Switzerland.
3
Department of Oncology, University Hospital Zurich, Zurich, Switzerland.
Received: 14 February 2013 Accepted: 16 July 2013
Published: 19 July 2013
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